How Do We Measure Health Care Quality?
What is the motivation to innovate? In healthcare it’s all about solving problems. But what are the things that are receiving the focus and the resources? Three kinds of innovation can make health care better and cheaper. An article in the Harvard Business Review, Why Innovation in Health Care Is So Hard by Regina E. Herzlinger states, “One changes the ways consumers buy and use health care. Another uses technology to develop new products and treatments or otherwise improve care. The third generates new business models, particularly those that involve the horizontal or vertical integration of separate health care organizations or activities.” The problem with this is that healthcare consumers in the United States are fairly uneducated as a whole. They don’t know what good looks like. They don’t have access to the data that would drive better decision making. Think about how you find a good doctor. What information do you use to evaluate why one doctor is better than another? Is it a Yelp rating? What your spouse told you? Or is that you just don’t like who you have and you’re just hoping that the next one will be better?
The truth is that even experts in the health care field are not really measuring health care quality appropriately. We’re measuring lab values, ER visits, satisfaction scores (including things like proximity of parking lots), HbA1c scores, hospital readmission rates, medication adherence, and other stats and metrics. Why is health care so often associated with treating disease? The truth is that these are what we measure to see if healthcare is working… But working for whom? There has to be a better way to measure what’s working and not working for consumers. Health is beyond the body. It includes our minds, our spirits, our emotions, our relationships, our careers, and so much more. We need to have a more flexible way to measure the quality of our health and the associated outcomes.
One problem is that health care is not a set of “cookie cutter solutions.” Health care professionals use “evidence-based medicine” but what does that mean? According to David Sacket from “Evidence based medicine: what it is and what it isn’t,” this is the definition:
Evidence-based medicine is the conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients
Current evidence that it will work for some. But where does that leave the people for whom the medication, treatment or therapy does not work? The point here is that it’s possible that health care should and can work for everyone if we were to only take a person-centered approach. There are things in the care of a person we can change and things we can’t. We can change peoples’ opinions perhaps. But we can’t change their past. And we shouldn’t be changing their beliefs and values.
Person-Centered Care Includes Being "Trauma Informed"
What if… there was a way to tell each and every person’s story. All the things that they’ve been through in their life that would contextualize things and inform care. For whole person health, this is critical. Behavioral Health professionals learn and use a concept called “Trauma Informed Care” which shifts the focus from “What’s wrong with you?” to “What happened to you?” If we know what happened, we can understand what the needs are and what care must be provided. Things like neglect, abuse, traumatic experiences, and loss. But in many cases the story isn’t documented or available to new service providers which means that people have to tell their story over and over and over.
The lives of foster children would be improved if the didn’t have to repeatedly tell their stories. There is a technology that exists so that they don’t. It’s called P-CIS (pronounced “pieces”).
That in of itself is traumatizing. And it can trigger a person if they relive those rough experiences that they have to talk about in order to get the care that they need so desperately. If only there was a better way.
Flexible Outcomes Measurement
When you go to the doctor, what do they ask? Here it is: they elicit a complaint. They want to know what’s wrong. They want to, in essence, “fix you up.” Health care professionals get to the what’s wrong but seldom to they come to understand the goals of the person, what’s important to them, what needs or symptoms that are preventing them from achieving their life’s goals or their goals in care. Think of how short doctor visits are. Some people spend more time waiting in the drive through at a fast-food restaurant than they do with their provider. Some of the best doctors I’ve had have gotten into the details and have addressed me getting better as a whole person. But that’s rare. Especially nowadays. Wellbeing, which is the “state of being comfortable, healthy, or happy,” is really larger than what we experience with health care. It’s whether or not someone is satisfied with their life as a whole. Once again, let’s acknowledge that some providers get to know these things. However, are they being measured? Hardly.
Some people might argue with me on that. I’ll push back. A while ago I met my primary care doc (this was when I was eating, drinking, and breathing behavioral health 24/7). I asked her, “If I had mental illness would you know it?” She was candid with me. She said, “Probably not. I would have had to log into a different system to find that information and that takes a bit of time, so I don’t do it.” Then I told her, “And if I did I probably wouldn’t tell you because of my own stigma. I would be worried that you would discount the story of my sore knee because you thought I was crazy.” The problems are two-fold. One is that we have stigma all around (that should be extinct like dinosaurs). The second is that we don’t share the information about a person that could help them be their best, cut down on healthcare costs, or even save some one’s life. More about this last point a bit later in the article.
Time to Track Needs and Strengths
If you take things to the next level, you measure and track a person’s needs and strengths. People with complex health care needs usually come with some strengths. And they should be used in care. Maybe a person has a great memory. Or perhaps a person is very organized. I can envision an organized person who has been diagnosed with cancer keeping their meds, diet, and other important aspects of their treatment in order. So that they can be followed. Moreover, being disorganized results in clutter and that causes stress, which is the enemy of getting better. In the case of building strengths, it’s important to know what we need to help people develop or build upon. Physical, mental, and emotional health are all critical for us to achieve resilience.
Behavioral health professionals use strengths in care all the time. For example: A strength-based care plan is one that utilizes strengths someone may already possess to meet a need. For example, if someone who is dealing with anxiety but is overall optimistic, then a clinician may engage them from what a ‘better day looks like’ and then using (Cognitive Behavioral Therapy/CBT) break down each step they need to take to decrease anxiety within a typical day.
Needs (or symptoms perhaps) must also be documented and measured, over time, to know if the number or severity of them is diminishing or increasing over time. Currently the metrics we use to know whether a person is improving their health are not very telling. We see insights on aspects of their health, but not the whole person. We monitor (track) pain, blood sugar, PSA levels (re prostate cancer), status of infections (e.g., strep throat), and other things. But these things measure part of person, not the whole person. In behavioral health, we perform an assessment pre and post care, but what happened in the middle? Much of the data is missed. We don’t have a true picture. We don’t know if the number of needs diminished or increased. And we don’t know if the most important needs (that impact wellbeing and align with the person’s goals in care) were successfully addressed or not.
In behavioral health we measure thinks like anxiety (GAD7) and depression (PHQ9) (Shout out to Dr. Eleanor Castillo Sumi, she knows why). But if they’re measured a year apart, what happened in-between? Too many times an initial screen takes place, but it sits trapped within the Electronic Health Record collecting cobwebs and adding little-to-no value to the provider and especially to the person in care! What if…. questionnaires, assessments, screenings, and other person-centered information became dynamic? A living record of how that whole person was doing with data of all kinds assembled to provide the whole picture of a person’s health and what matters to them? And what if that story could be created and then updated in real time and shared with all the people who were responsible to take care of people and meet their whole-person health needs? That would change everything.
A topic that I think about often is suicide. My heart breaks for those who lose a loved one who takes their own life. This is preventable. Suicide is a permanent solution to a temporary problem. But that doesn’t mean that the problem feels temporary to those who are suffering from severe depression. When I worked at Relias, we provided online training solutions to help behavioral health organizations (my heroes) meet the needs of those suffering and feeling hopeless. We even partnered with the United Kingdom to train everyday people to notice the signs of the depression and what to do about it. How to take action! The partner was the Zero Suicide Alliance. Take time today to learn these important skills. You could literally save a life.
The ability to put together persons’ stories to inform care, to transform care, and to measure the effectiveness of care in a new, profound way would be outstanding. But if I was getting out my wish list, I’d see that I’d want the ability to augment that story in real time with new assessments or questions sets from consumers of services and those involved in their care. How amazing would it be if an AI bot (e.g. look at the fascinating technology of a company called “Humaxa“)…could monitor a person’s depression? As the information changes over time and thresholds are crossed, a clinician could engage and prevent suicide or self-harm? As technology advances, we need to innovate and figure out how to do more with less. And what if that person with depression’s story was updated in real time so that more people who were in contact with person (primary care, behavioral health, a professor, a loved one) had access to information that could save their life? There is something enormously powerful to timely interventions. That’s a solution to a problem that I want to be part of… And I can think of a very special group of men and women whom we could help.
Our heroes, the veterans of America’s armed forces, our military. And those active-duty members of the Army, the Navy, the Air Force, Space Force, the Coast Guard, and the Marines (A special shout out to all that have served our country including my Great Uncle Barney, my Uncle Bob, and my brothers-in-law: Terry, Troy, and Randy.).
But with all these technologies there would still be something critical missing. The ability to help people with similar challenges, circumstances, opinions, and preferences. I wish that we could use the story maps to predict what care would work for whom. What if we got people being their best faster? What if, even with the difficult sets of circumstances, we could find success from the people served in the past who did experience success? That would be powerful. And it would help us address some of the issues related to workforce shortages. The problem for behavioral health agencies related to losing staff and their inability to hire new staff fast enough is brutal. Many people don’t really realize that behavioral health care agencies (Once again, my heroes. My mom, who passed away in December, was a retired psych nurse, what they do for our loved ones is beyond commendable.) are not only stressed by their inability to serve the people of their community, but they are also losing revenue when they lose staff. This is so tough because behavioral health orgs operate on tight margins, sometimes even razor thin.
Some of the biggest challenges we face in healthcare involve economics and staffing shortages. Not only global pandemic related shortages. Just run-of-the-mill, pre-Covid19 staff shortages. The Covid problem just exacerbated an already bad problem and made it almost unmanageable. A analogous situation is the opioid epidemic. We’re headed towards a crisis that made the Opioid Epidemic from a few years ago look relatively tame. It’s already here. People are not talking about the fact that more people between ages 18-45 die from fentanyl overdose than any other reason. Cancer, suicide, car accidents, and yes, Covid… None of these things kill as many people in this demographic as fentanyl overdoses. And even more terrible is that it’s killing America’s young people, our future.
I digress. Back to challenges related to economics and staff shortages. Staff shortages are hitting every industry. In many situations, behavioral health professionals are not compensated as well as people in other industries and other sectors in healthcare. Financial situations can become enough of a factor that behavioral health staff leave for other jobs. Stress levels are also incredibly high based on the pressures associated with the job. In the article, Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public Health Priority, the authors note, “Numerous factors contribute to elevated stress among healthcare workers, including heavy workloads, long shifts, a high pace, lack of physical or psychological safety, chronicity of care, moral conflicts, perceived job security, and workplace related bullying or lack of social support. The resulting psychological distress can lead to burnout, depression, anxiety disorders, sleeping disorders, and other illnesses. Work related stress can have a negative impact on health care providers’ professionalism, quality of care delivery, efficiency, and overall quality of life. Therefore, it is critical to identify and mitigate these work-related risk factors to protect the mental health and well-being of healthcare workers.”
Front. Public Health, 07 May 2021 | https://doi.org/10.3389/fpubh.2021.679397
Addressing these stressors, especially the heavy workloads, could have a significant impact on a behavioral health agencies ability to retain staff. Taking care of the healers in our nation should be a high priority. But from doing a scan of behavioral health agencies, few are tapping into innovations that are scalable, affordable, and sustainable to impact some of the staffing challenges plaguing the country. Is it because they don’t exist? Or is it something else? I think in many cases these organizations are in survival mode. They’re experiencing something like fog of war and taking action and innovating isn’t easy or even plausible in this environment.
“I think in many cases these organizations are in survival mode. They’re experiencing something like fog of war and taking action and innovating isn’t easy or even plausible in this environment.”
My dear friend and colleague, Dr. Kate Duggento Cordell, has been working as a researcher, consultant, and problem solver in whole person health for over twenty years. She has consulted every county in California (data, analytics, much more) and has done work across the country as well. She’s on the faculty at the University of Kentucky contributing to the Center for Innovation in Population Health. While working on her consulting projects she realized that all she was doing was really “stamp collecting.”
The software and data pathways that she developed were all brilliant ideas. But because they were usually grant funded, one-off projects, when the grant monies dried up the solutions ended up dying on the vine. She said to herself, “I have to start a company so that these concepts and technologies can be sustainable. I need to make these revolutionary ideas into something that’s scalable and repeatable. I need to create a health care software startup. It’s the only way to solve these problems.”
And so, she co-founded Opeeka. Many folks ask her, “Where did you get the name?” She replies, “Opeeka means ‘resilience’ in Telugu and it means ‘care’ in Polish.” Kate and Co-Founder Ken Knecht wanted a unique name (hence the spelling) and something that described what the technology company is aiming to achieve. That is: Trajectories towards resilience and well-being for all.
“Resilience” in Telugu
Opeeka set out to do all the things mentioned in earlier in the article. They successfully built a web-based software that:
- Judiciously and automatically shares private data across different systems (e.g., Education, Justice, Child Welfare, Behavioral Health) and care circles
- Measures clinical outcomes (including Patient Reported Outcome Measures) in a more dynamic, flexible way
- Monitors whole-person outcomes in real time
Now payers, providers, and governments could share information and insights with many providers to: inform care, reduce duplicative work, to drive better outcomes, to become and stay in compliance with new rules that come out of legislation (see this information on AB 2083 and “How P-CIS Enables Coordinated Care For Multi-system Served Children, Youth And Families”), and to ensure that care is patient centered, success focused, and meeting the needs (and building upon strengths) of the whole person. The creator of the “CANS” (Child and Adolescent Needs and Strengths) and TCOM (Transformational Collaborative Outcomes Management), Dr. John Lyons, is one of Opeeka’s best supporters. The ability to take the CANS and other clinical tools and track the movement of skills, needs, strengths, and trajectories towards resilience has been sorely missing in health care. Not any longer now that P-CIS (Person-Centered Intelligence Solution) was invented by Dr. Kate Cordell and Opeeka. They didn’t just figure it out… They nailed it!
Kate and team earned this praise from Dr. Lyons, “Opeeka might be the only heath care technology company out there that really gets it. Their Person-Centered Intelligence Solution has transformed care planning and clinical decision making. Clinical tools like the CANS are even more dynamic because of the newfound capability to measure the resolution of needs and the trajectories of recovery and resilience over time.” The Professor from the University of Kentucky and head of The Center for Innovation in Population Health, Health Management & Policy approaches are used to help serve more than 1.5 million people each year. They are all based on a new theory of measurement, Communimetrics, developed by Dr. Lyons. This theory posits that in human serving enterprises, measurement’s primary purpose is communication which must be considered much more broadly than communication among scientists. As such, Communimetrics is based on optimizing the communication value of the measurement approach. P-CIS incorporates Communimetrics in how it flexibly collects information about persons in care which becomes part of a “story map.“
P-CIS tracks recovery and resilience over time. In addition to tracking changes in needs and strengths, PCIS generates a story map which helps illustrate a person’s circumstances. The story map transforms assessments into a visual map so that members of a circle of care can focus on needs and strengths, while considering underlying items and background needs. Automatically built from surveys, questionnaires, assessments, and other data sources (often found in an Electronic Health Record (EHR)), the story map quickly shares a person’s story, the all-important, contextualized information about their identity and their history (e.g., past trauma, history of domestic violence, being part of a tribe, etc.). Likewise, it includes a person’s circumstances and preferences (many of which involve #SDoH or “Social Determinants of Health”), their needs in the background (something to know but not a current area of focus), their opinions (e.g., my voice isn’t being heard regarding my care), and their goals in care (This is huge relative to making health care person-centered. My mom taught me that people with mental illness, for example, are people too. With hopes, dreams, aspirations, careers, hobbies, and everything else. They just have problems that I wouldn’t wish on anyone and for which they didn’t ask. They need even more of our love and care but unfortunately, they are often marginalized, vulnerable, and experience feelings of hopelessness, defeat, frustration, and fear.). To love is to provide for the needs of others. Providers, therefore, are loving people and because of this they have my utmost respect.
Perhaps most importantly the story maps include the needs and strengths that I alluded to earlier. If it’s my loved one (and I have loved ones who have mental health and behavioral health needs, and most people do with one out of every three people have a condition, diagnosed or not) or me in care, this is so important. I learned at my career with GE Healthcare that, “If it’s important you measure it.” What’s more important than a person’s needs? Wouldn’t you want someone you love to have as many strengths as possible to be their best in this life? You bet you would.
Opeeka’s story maps found in P-CIS are not updated monthly, not weekly, not daily, but in real time! Every day in America people are experiencing depression and anxiety. Imagine two people. One being treated, one not. If they both end up in the Emergency Room, in neither case will the hospital staff know about what these people are experiencing, the treatment the one received, or if they’ve been getting any help at all. It’s all a mystery. It’s starting at ground zero. Imagine a woman who was molested growing up, sexually victimized to this day, with opioid addiction, chronic anxiety, and depression, showing up at the emergency room unconscious. The ER team doesn’t want a male doc to put his hand on his shoulder. And it would be wise to have a crisis intervention team ready when she restores consciousness. But this couldn’t be known without this woman’s story map, which helps clinicians and others know about a person so that they can help with their needs and strengths. In addition, to help them achieve greater wellbeing and move towards achieving resilience. It is not a trait that people either have or don’t have. It involves behaviors, thoughts, and actions that can be learned and developed in everyone.
With the technology we have access to today this should not be. And because Opeeka set out to change this, to do something perceived as “too difficult,” despite all the siloes, to go to a place where innovation was seemingly absent, multidisciplinary providers can access the right insights, the right information (no more, no less) in real time. With P-CIS, in the ER example above, the doctors can see what’s going on. They have information and insights into the person’s story. Whether it be information from a behavioral health or integrated care facility or from a pulse survey filled out online prior to reaching out for help, there are important details to meet the care needs of people, to start listing the strengths they have and need to build, and to inform the team of people that are there to help with tough situations and circumstances (e.g., being a victim of domestic violence). This data could be supplemented with a person’s health history, family health history, pharmacy information, pharmacogenetic testing info and much more. This is what Opeeka calls the “super story.”
“What is pharmacogenetic testing? Pharmacogenetics, also called pharmacogenomics, is the study of how genes affect the body’s response to certain medicines. Genes are parts of DNA passed down from your mother and father. They carry information that determines your unique traits, such as height and eye color.”
You might be thinking that this must already exist. Sure, health systems have a lot of information in one place. For example, a large company called “EPIC” out of Wisconsin has what they call “MyChart.” Hospitals and health systems from all over the country brand this solution concocting all sorts of names. This is definitely helpful. But in the situations described above it misses the mark. Getting to the essence of a person and their story and knowing what the specialists needs to know versus others with distinct roles, knowledge, and responsibilities isn’t easy. It has to be succinct, visual, actionable, and ultimately useful and impactful. Imagine children with behavioral health diagnoses. With P-CIS you can share information with teacher and paraprofessionals for instance. Would it help to simply relay in a list of other things pertaining to “Johnny” that he has ODD (Oppositional Defiant Disorder)? Or, would it be more helpful to share that, “Johnny argues frequently with adults, particularly the most familiar adults in their lives, such as parents. Johnny’s treatment plan includes identification of triggers, both external and internal. Some external triggers to include in treatment planning may include when Johnny gets ‘over-whelmed’ with both the number and priority of steps needed to complete task. Johnny’s reaction when this happens is to become aggressive towards others and throw things. These ‘steps’ when provided to Johnny beforehand will be to prevent escalation and triggering his oppositional behaviors. Additionally, internal triggers could be part of the care planning process in increasing Johnny’s understanding of his feelings & emotions in support of both awareness and management. Overall, Johnny’s progress will become the focus of treatment rather than just a label or diagnosis which can often stigmatize increasing blaming and shaming.” P-CIS supports success-focused care rather than solely on risk management. The shift allows for individual growth towards overall increased health and wellbeing.
This concept of sharing the right information (no more, no less) to various members of an inter-disciplinary team in real time cannot be stressed enough. It’s really important. I can speak to this from personal experience. My wife and I fostered and adopted two children with special needs. One of them, my son, has autism and ADHD. Having P-CIS back when he was an infant or even a toddler would have helped so much. There were teachers, social workers (and there was turnover there), adoption agency workers, behavioral health specialists, primary care, and others all doing their best to help him. Problems was that they created 100-page reports that didn’t get read. They all had different information on how they were helping Kai, but it wasn’t very coordinated. The ABA therapists were never able to impart the knowledge and skills to help Kai day in and day out. This led to thoughts and feelings that I was failing Kai as a daddy. I wasn’t. But I still felt helpless and that there was something more that I or someone else should have been doing. Technology like P-CIS could have dramatically improved the situation and helping my son be the best version of himself that he could be. Everyone on literally the same page with each person in Kai’s care circle getting the information and insights they need, no more, no less. In addition, getting information from us, the care team members, in the form of surveys done on a mobile device (Opeeka calls it their “invite to complete” process) would result in the latest information available in real time. Trying to tell people how Kai has been doing over the last month from memory isn’t easy. And remembering to report on the things given by the ABA therapists was rarely done in the moment. Usually, it was a week later when the experiences we had with Kai’s behavior were not fresh in our minds. With technology and innovation we can all do things smarter.
Opeeka really took things to the next level when they launched their Success-Focused Artificial Intelligence (SF-AI). This proprietary, one-of-a-kind technology was developed by Dr. Kate Cordell. Her data models have all been published in peer-reviewed journals (Learn more by clicking here). With a person’s story map clinicians can compare that story to other similar people whom they have treated successfully. This is what Opeeka calls, “Care Compare.” It’s like an asynchronous “grand rounds.” A grand rounds is:
“A formal meeting at which physicians discuss the clinical case of one or more patients. Grand rounds originated as part of residency training wherein new information was taught and clinical reasoning skills were enhanced. Grand rounds today are an integral component of medical education. They present clinical problems in medicine by focusing on current or interesting cases. They are also sometimes utilized for dissemination of new research information.”
Except with Opeeka, the information is available in real time and can work with as few as 150 patients (historical data) to find the patterns of success. Knowing where to start and what’s most likely going to be successful is a huge win for behavioral health providers. With this technology front-line staff can instantly know what care, what therapies, at what intensity, in what setting, for what duration, etc. that has been successful for people who have very similar stories to the person they’re caring for right now. Opeeka’s early estimates state that over $1,000 is saved for each person in care per year. This is because there the time in care is shortened for persons to achieve their goals. This is thanks to Care Compare and the other technologies seamlessly woven into clinical workflows. Single sign on (SSO) technology is used so that people aren’t logging into a new system, just using P-CIS technology from within the systems already in place (e.g., EHR software, case management platforms, etc.).
We are entering a brave new world. The innovators will be the organizations that embrace new technology and take risks for those who cannot influence these decisions, the people with complex needs and limited financial resources. We owe it to our neighbors, fellow citizens, and our society to advance medicine and health care to treat the whole person. With technology like Opeeka’s we don’t have to break down the silos. We can thrive and flourish in spite of them. The cost of sharing information (and sharing results in better caring) pales in comparison to the consequences of isolating a person’s story and key information and insights. When we predict what care will work for whom we all win. It about time that we all consider abandoning the stamp collecting. Now is the time to focus on person-centeredness and healthcare technology that transforms.